Why hip patients need to be told: Stop being so cautious
After surgery to replace her right hip joint, Christine Walker was handed a pair of crutches and a photocopied sheet of illustrations, demonstrating the best way to use them when climbing stairs.
‘I was told to come back to see the surgeon ten weeks later to check that the scar had healed and to stay away from the gym for at least three months,’ says the 73-year- old retired teacher trainer and grandmother of four, who lives in Middlewich, Cheshire, with her husband John.
‘Of course, I followed the instructions to the letter. the last thing I wanted to do was to risk damaging the new hip. After the ten-week check-up, I went back to the gym and got a specialist assessment of how I was doing.
‘It was a shock to discover I was limping quite badly without realising it.
‘If I hadn’t pushed myself to get back to my normal levels of mobility, I might well not be the active, healthy lady I am today.
‘It’s crazy. the NHS invested in this fantastic and very expensive operation to relieve the pain — and then you’re left to get on with it.’
Hip replacements are widely regarded as a great surgical success story. every year, 90,000 procedures are carried out in Britain.
Hip replacement surgery was dubbed the operation of the century in a paper in the Lancet in 2007 for ‘revolutionising the treatment of crippling arthritis’.
NICe says it is the second most successful procedure in terms of improving quality of life, after cataract surgery.
But a major review recently published in the journal Clinical rehabilitation found that after having a hip replacement, people are no more active or healthier (measured by heart and lung tests) than they were immediately before.
‘It appears that when scientists use objective measures, the research shows there is no significant difference in physical activity after patients undergo this very common procedure. Patients do no more exercise after a hip replacement than beforehand,’ says the lead researcher Dr toby Smith, a lecturer in physiotherapy at the University of east Anglia’s School of Health Sciences.
‘And that’s a serious problem given that osteoarthritic pain, the primary trigger for seeking a hip replacement, reduces mobility dramatically.’
the problem is that access to physiotherapy is limited or nonexistent after surgery.
Another problem, say experts, is that advice given to patients to avoid certain movements for fear of dislocating the new joint is counterproductive and outdated. Indeed, last weekend they called for the advice to no longer be given.
WHeNit comes to physio, ‘many patients don’t have access to a therapist who can provide the reassurance and encouragement to help them perform daily exercises to strengthen the muscles that will keep their new hip healthy’, says Anthony Gilbert, a senior physiotherapist at the royal National Orthopaedic Hospital NHS trust in Stanmore, North-West London.
‘Most people who have osteoarthritis serious enough to need surgery will have muscle weakness and functional limitations from years of coping with the pain, as well as from the surgery.
‘It’s not enough to get rid of the pain. there’s also a need to identify and correct these problems to help patients live full, active lives.
‘Some hospitals do this. At my hospital, a patient will see a physiotherapist within two weeks of surgery. Yet I have worked at a number of other hospitals where people who have hip replacements are never referred to a physiotherapist.
‘It means that the only health professional many see after the operation is the surgeon at the follow-up appointment.
‘that’s a five-minute appointment where they’ll check the X-ray to make sure the stitches have healed.’
Claire Small, director of Pure Sports Medicine, a London-based orthopaedic clinic that treats large numbers of hip patients, adds that ‘many orthopaedic surgeons are frustrated that they cannot routinely offer physiotherapy to patients’.
‘Surgeons know that while they replace the damaged joint, this does nothing to improve the strength of the muscles.
‘People who don’t get physiotherapy can end up with the same problems as before surgery, often limping or with incorrect posture.’
Professor Alister Hart, an orthopaedic surgeon at the royal National Orthopaedic Hospital who specialises in hip replacement, says ideally all his patients would get physiotherapy from day one, once a week for the first six weeks.
‘It’s not simply a problem with the NHS,’ he says.
‘Private health insurance will reimburse clinics for the operation, but won’t pay for physiotherapy.’ An added concern is that medical professionals inadvertently make patients too anxious to exercise.
Nine out of ten of 170 physiotherapists and occupational therapists routinely advise their patients to take ‘hip precautions’.
this advice includes the need to avoid flexing, extending or rotating the hip for between six weeks and 12 months post- operatively, according to a survey published in the journal Musculoskeletal Disorders earlier this year.
the advice may sound sensible. But earlier this year, the authoritative Cochrane review looking at the quality of advice given to hip transplant patients found no evidence that hip precautions are necessary or that there is any difference in complication rates such as hip dislocation when the advice is ignored.
‘ It is important that correct information is given to patients to encourage and not to fear movement,’ says Aislinn Shattock, a physiotherapist in Weybridge, Surrey, and a member of the executive committee of the Association of trauma and Orthopaedic Chartered Physiotherapists.
‘Yet eight out of ten hospitals still advocate the use of precautions, often without timescales to alert the patients when they can stop applying them.’
At its annual conference in Oxford on Saturday, the association called for an end to the practice of advising patients to restrict hip movements after replacement surgery.
‘Our priority must be to encourage people to be more physically active after a hip replacement — not to tell every single patient to avoid twisting, turning and bending,’ Dr Smith told the meeting.
Christine Walker was working fulltime when she had the operation, aged 65, and says she was determined to stay active — she is a keen gardener and a gym member.
the operation went well. ‘I was in pain for the first few days, but the grinding osteoarthritic pain had gone. Straight away I was chomping at the bit to get back to the kind of exercise I used to enjoy so much,’ says Christine.
Yet the hospital made no mention of physiotherapy. At the gym, once her surgeon had given her the OK, Christine’s concern was not whether to exercise, but how to do it safely.
‘I was so lucky that a rehabilitation expert specialising in implant surgery was working at the gym and I was able to book sessions with her — an hour a week to start off with.
‘It took me 18 months to get back to my previous state of fitness and the level of activity that I now enjoy.’
However, not all experts are convinced by the latest findings about lack of improved mobility and fitness post-operatively.
PrOfeSSOrHArt says that he ‘was astonished to read these very negative reports of hip replacement when the outstanding fact about the operation is that patients are so satisfied’.
Mark Wilkinson, a professor of orthopaedic surgery at the University of Sheffield, says the research ignores ‘ the personal satisfaction and sense of achievement experienced by a typical patient who is able to walk short distances with a stick after being wheelchair-bound for years.
‘this is an operation designed to improve pain and make it possible for people to do things that they want to do in comfort. It’s not about enabling people to take up running.’
Indeed, a separate review of research into patients’ attitudes post-hip replacement, carried out by Dr Smith and published in the BMJ last year, found that many had ‘relatively low expectations’ for their future lifestyle.
‘People want to be out of pain and able to undertake normal daily activities — gardening, housework, walking the dog, going to the shops,’ says Dr Smith.
‘they don’t want to achieve anything extraordinary. Just returning to these kind of activities is seen as a major improvement.’ But behind these modest aspirations, he says, is the desire to stay safe.